round cells and ameboid cells from the chick. The ameboid cells cultivated in plasma alone continued to produce ameboid cells. Cells cultivated upon silk in plasma lost their ameboid quality, became elongated, and formed a network or chains. Also, round cells. taken from a culture of connective tissue 74 days old multiplied rapidly, became transformed into elongated cells, formed a mass of dense connective tissue. The culture was growing rapidly at the end of more than three months.

CONTRIBUTION TO THE BACTERIOLOGY OF PERITONITIS; WITH SPECIAL REFERENCE TO PRIMARY PERITONITIS

Med.

Fishbein (Amer. Journal Med. Sciences, Oct., 1912,) has studied 184 cases of peritonitis on the post mortem table. He followed the classification of Flexner by which all cases of peritonitis are divided into. 1. Primary type-Occurring as a result of previous chronic disease or an infectious focus elsewhere in the body, the infecting agent being brought to the peritoneum by way of the blood or lymph channels. 2. Endogenous type-in which the infection comes from an abdominal organ, usually the appendix or the female generative organs.

The

This is the most frequent type. 3. Exogenous type-in which the peritoneum is infected from without, usually by means of trauma or instrumentation, operation, etc. The infection may be pure or mixed. The colon bacillus, streptococcus, staphylopneumococcus, typhoid bacillus, bacillus proteus, bacillus mucosus were the organisms found in the order named, the colon bacillus being by far the most frequent offender. Its presence was noted in 83 out of 126 cases. Strange to say the gonococcus was

coccus,

never recovered from the peritoneum, post mortem.

In the primary type, which formed 25 per cent. of all the cases, especially when it was combined with sepsis, the streptococcus was quite as frequently a factor as the colon bacillus. In typhoid perforations the typhoid bacillus was found.

In 39 cases of primary peritonitis pneumonia was a factor in 18 cases. In 4 cases suppurative foci distant from the peritoneum were present. In 7 cases there was an associated chronic endocarditis or pleuritis. In 4 cases hyperplasia of lymphoid tissue was marked. In the remaining cases marasmus, congenital syphilis, cirrhosis of the liver and blastomycosis were factors. It is important to note that the tonsil may be a factor in some of the cases of primary peritonitis, and may explain the mode of entrance of the infecting organisms in cases of idiopathic peritonitis in marantic infants.

THE ALBUMIN REACTION OF THE SPUTUM IN PULMONARY TUBERCULOSIS

According to Fullerton (Glasgow Med. Journal, July, 1912,) the examination of the sputum of a large number of patients shows that appreciable quantities of albumin can be detected. in the sputum of sufferers from pulmonary tuberculosis. Albumin is also occasionally found, tho much less frequently, in acute bronchitis and in pneumonia in the febrile stage and in the stage of resolution, and in bronchiectasis. Albumin was not found at all, or in minute quantities, in the sputum of cases of bronchial "catarrh," in the resolving stage of acute bronchitis and pneumonia, and in chronic bronchitis.

to render the bile an unsuitable medium for bacterial growth. From these facts, one would conclude that hexamethylenamine would be of great value in the treatment of acute infections of the gall bladder and bile passages and especially when the offending organisms are either the colon bacillus or the typhoid bacillus. In a like manner, the drug would be of service as a protective when given before operations on the gall-bladder and bile ducts.

These observations together with others concerning conditions which may be favorably influenced by the administration of hexamethylenamine, have been recently published by Crowe (Bullet. Johns Hopkins Hosp., Sept., 1912).

It has been experimentally and clinically determined by Crowe that hexamethylenamine when given by mouth or rectum, appears in the cerebrospinal fluid and that the concentration of the drug in the cerebro-spinal fluid reaches its maximum in from one-half to one hour after administration. He has also determined that the drug when administered within therapeutic limits, appear in the cerebro-spinal fluid in sufficient concentration to practically inhibit the growth of organisms (streptococcus) inoculated into this fluid after its removal from the body. Crowe also observed that the onset of a fatal meningitis could be deferred and often prevented in dogs that received subdural injections of virulent cultures of the streptococcus, providing that 60-80 grains of hexamethylenamine were given daily.

Since these experiments were begun, it has been a routine measure at the Johns Hopkins Hospital to administer

in

hexamethylenamine to all cases which surgical infection is a possible or threatened complication.

In a series of twenty compound fractures of the skull occurring at the hospital, twelve cases received the drug immediately after the injury and at frequent intervals thereafter. Ten of these recovered. In eight of the earlier cases in which the drug was not given, there was a mortality of 50 per cent. In a series of 40 cases of hypophysis tumor operated on in Johns Hopkins Hospital, hexamethylen was administered as a prophylactic in doses of 40-60 grains during the 24 hours preceding the operations and in larger doses for some days following the operations. No post-operative complications occurred in 31 of these cases; of the remaining 9 cases in which complications occurred, only 3 died of meningitis.

Since it has been demonstrated that hexamethylenamine is excreted my the mucous membrane of the middle-ear, the administration of this drug is indicated in all cases of otitis media where extension of the infective process is to be feared. As a prophylactic against otitic complications occurring during scarlet fever, the drug is also to be recommended, according to Crowe. Chronic ear discharge has been frequently noted to change in amount and character, during the administration of hexamethylenamine, due to the excretion of the drug into the tympanic cavity where it inhibits the growth of bacteria.

From the fact that the drug is also excreted into the accessory sinuses of the nose, it is very probable that it is also of value in the early stages of acute coryza when given in sufficiently large doses, and in preventing the

chronic infections of these cavities, especially infections of the Antrum of Highmore.

Gradle and others have found that hexamethylenamine is excreted into the anterior chamber of the eye and is of value in the treatment of various ophthalmic infections.

Flexner and Clark injected the virus of poliomyelitis intracranially into monkeys in whom hexamethylenamine was already present in the cerebrospinal fluid. The drug was then administered daily thereafter. In many of the animals so treated, the incubation period of the disease was prolonged (from 6 to 8 to 24 days); and in many the onset of paralysis was entirely prevented. Since the prophylactic value of hexamethylenamine in experimental poliomyelitis has been proven, the Massachusetts Board of Health has recommended that the drug should be given as a prophylactic during an epidemic of this disease. It is only during the very earliest stages of poliomyelitis, when there is a leptomeningitis preceding the involvement of the central nervous system, that any positive results may be obtained with hexamethylenamine. A few cases of epidemic cerebro-spinal meningitis have been reported cured as the result of a systematic use of this drug.

In Crowe's experience, the toxicity of hexamethylenamine is not very great. The administration of doses of 200-300 grains daily in adults and 100-125 grains daily in children, for four or five days have been repeatedly observed by him. In none of these cases were toxic symptoms noted, provided that the drug was sufficiently diluted. Few patients are, however, susceptible to the drug in doses of even 5-7 grains. In a series of 95 cases

in which hexamethylenamine was administered in daily doses of 75 grains for ten days, painful micturition and hematuria occurred in only seven cases. Other untoward effects noted by Crowe were skin rashes, gastric irritation, and catarrh of the mucous membranes.

These usually arise from insufficient dilution of the drug and disappear rapidly when diuresis is established.

According to Crowe, the best way to administer hexamethylenamine to very sick patients is to dissolve 50-100 grains of the drug in one litre of normal saline solution and to administer this thruout the day by the drop method, per rectum. For those patients who can take nourishment, 2 or 3 grains are added to each ounce of fluid taken by the patient. In this way 60-100 grains a day may be administered without the patient's knowledge, and without producing gastric irritation or other untoward symptoms.

LUPUS ERYTHEMATOSUS Lupus erythematosus is a not uncom mon disease of the skin occurring more frequently in women than in men. It is of interest to the general practitioner on account of its supposedly toxic origin and its long and persistent course in spite of treatment. Tuberculosis, arthropathies, and chillblains. are often associated with the disease.

The typical lesion of lupus erythematosus begins as a small erythematous patch, only slightly raised, which spreads from the periphery, at the same time healing at the center, where a thin smooth atrophic scar is formed. Several of these patches may become confluent forming one or more larger patches. Scattered over the patches. are numerous flat yellowish scales which, when removed, reveal the

mouths of the sebaceous glands which they cover. The patches never ulcerate and no gelatinous nodules are formed as in lupus vulgaris. There is no itching or oozing as in eczema, and the scales when removed, leave no bleeding surface beneath, as in psoriasis.

The site of election of the lesion, is usually the face, especially the nose, from which it spreads laterally onto the cheeks in the well-known butterflyfigure. Other frequent sites are the forehead, scalp, ears; rarely does it occur on the extremities or body. This description holds good for the chronic or so-called "discoid" variety of the disease. Lupus erythematosus may, however, occur as an acute disease, with disseminated lesions all over the body, high temperature and symptoms of a severe toxemia resulting in death in not a few cases. The acute form of the disease occurs usually in female patients who have shown previous lesions of the chronic variety, and being very rare, needs no comment, excepting for the fact that it might occasionally be mistaken for erythema multiforme.

The lesion of lupus erythematosus is limited to the superficial layers of the skin and deep scarring is never observed; occasionally the lesion disappears spontaneously, only to reappear some years later in the same or in some other location. When the lesion oc

the patient should always be under careful observation and the general health should be improved as much as possible; anemia is usually marked.

Of the internal medication most suitable for the treatment of the condition, the use of quinine has been most lauded. This must be given over long periods of time in doses of 0.5-1.0 per day, alone, or in combination with small doses of arsenic.

Of the local measures that are used, the following are said to be the most useful: tincture of iodine applied lightly to each patch; either full strength or with equal parts of glycerine. Equal parts of alcohol and ether applied hourly with a soft brush; salicylic plaster; Fowler's solution 1:3. When too severe a reaction follows the use of these medicaments a mild ointment may be applied until the inflammation subsides. For the more chronic patches, liquid thiol applied every few days and allowed to dry, is often of benefit when used over a long period. Great care, however, is necessary in the use of tar preparations as the lesions are occasionally made worse by their application.

Of the modern topical remedies for lupus erythematosus, carbon-dioxide snow is of most use; of less value is the X-ray, radium and the Finsten light, all of which may occasionally aggravate the condition.

In the treatment of lupus erythematosus, one must keep in mind the fact that the disease has been, and still is considered in the nature of a chronic toxemia, of which the toxins of tuberculosis may be a cause. The lungs of

ADULT: ITS SIGNIFICANCE

AND TREATMENT

Frequency of urination is a term applied to a decided increase in the number of times that micturition is initiated, tho the amount of urine passed each time may vary from a few drachms to enormous quantities.